Coverage Determinations
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Defines Longevity Health Plan of Colorado's process for making coverage determinations, prior authorization, and evaluation of new technologies for plan beneficiaries; applies to UM decisions and providers rendering care under the Plan.
No material clinical or coverage changes in this revision.
Coverage Determinations & New Technology Evaluation
Decision-making hierarchy
UM decisions must follow the hierarchy below when determining medical necessity:
Sources are applied in order and considered together when making determinations.
New Technology Evaluation (must meet all)
New technologies (including procedures, pharmaceuticals, and devices) are covered only when ALL of the following are met:
Acceptance by national standards, specialty society position statements, clinical practice guidelines, or CMS/FDA determinations are additional considerations.
Technologies that fail to meet the Plan's objective new-technology criteria are considered experimental and investigational and are not covered. The Plan requires that new procedures, devices, and pharmaceuticals demonstrate final regulatory approval (when applicable), peer-reviewed evidence of consistent outcomes or professional society recommendations, acceptance as safe and effective, measurable improvement in health outcomes, documented benefit outside investigational settings, appropriate setting and level/duration/dosage/frequency of use, and not be primarily for convenience or obsolete before coverage will be granted.
The Plan follows Medicare coverage parameters and will not cover services that are not covered by Medicare unless those services are explicitly included as a covered benefit in the Plan’s supplemental benefits or overall plan design. Services may be subject to prior authorization or referral per Plan processes.
Prior Authorization & Provider Responsibilities
Prior authorization required for some services
Some services require prior authorization. The list of services requiring prior authorization is published on the Plan website (www.longevityhealthplan.com); providers should consult that list to determine whether a requested service requires prior authorization.
- Prior authorization is required for some services.
- The list of services requiring prior authorization is available on the Plan website: www.longevityhealthplan.com.
No step therapy or formulary substitution for Part B drugs
For Medicare Part B drugs, the Plan does not maintain a formulary and does not require step therapy, therapeutic interchange, generic substitution, or formulary substitution; drug selection is at the discretion of the ordering provider.
- No step therapy, therapeutic interchange, or formulary/generic substitution for Medicare Part B drugs.
- Specific drug selection is at the discretion of the ordering provider.
Follow prior authorization process and submit supporting documentation
For services that are subject to prior authorization, providers must follow the Plan's prior authorization process and provide documentation supporting medical necessity; the Plan's pharmaceutical and authorization policies and procedures are available in the provider manual and on the Plan website.
- Follow the Plan’s prior authorization process for services that require authorization.
- Provide documentation supporting medical necessity as requested by the Plan.
- Authorization-related policies and procedures are available in the provider manual and on the Plan website.
Risk of denial if prior authorization not obtained
Services that require prior authorization but are not authorized may be denied. Providers should obtain authorization when required to avoid claim denials.
- Lack of prior authorization for services that require it may result in denial of the service.
- Obtain required authorizations to reduce risk of claim denial.
Policy Context & Evidence Sources
When making Utilization Management determinations, the Plan aligns with and applies CMS guidance and authoritative sources in a defined hierarchy: CMS coverage policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), the Medicare Benefit Policy Manual, and recognized utilization review criteria (for example, InterQual or Milliman). The Utilization Management Committee reviews criteria against current clinical and medical evidence and evaluates new technologies using the Plan’s objective criteria before coverage is approved.
Acronyms & Terms
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